Discussion
Bladder can be found in 1-3% of all inguino-scrotal
hernias1. The vast majority of these are small and
asymptomatic; they are therefore often diagnosed intraoperatively during
routine inguinal hernia repair2. When symptoms do
occur, they most commonly consist of two stage urination, in which
pressure must be applied to the herniated bladder to completely drain
it3. Other symptoms include non-specific lower urinary
tract symptoms such as dysuria, urinary frequency and urgency, or a
palpable scrotal mass1. Possible imaging modalities to
diagnose bladder herniation include non-contrast CT, CT urogram or
ultrasound of the urinary tract and scrotum1, however
it has been suggested that all patients receive a CT scan at some point
due to a weak association with urinary tract
malignancy6.
In this case the patient initially presented with acute urinary
retention, likely secondary to compression of the urethra below the
level of the herniated prostate gland. To our knowledge this has not
previously been reported in the literature as an initial presentation of
scrotal herniation. This was successfully decompressed with a urinary
catheter. While there have been no randomised controlled trials on the
subject, it is thought that surgical repair and preoperative
catheterisation is indicated in patients with symptomatic scrotal
hernias4. However, there is a high risk of damage to
the bladder5 and so it was decided to manage this case
conservatively.
This patient presented on a second occasion with urosepsis likely
secondary to upper urinary tract obstruction given the ultrasound
findings of bilateral hydronephrosis. There are few reports of upper
tract obstruction secondary to inguinoscrotal hernia in the literature,
and these cases are all unilateral6,7. On the
patient’s initial discharge it was thought that his bilateral
hydronephrosis was secondary to vesicoureteric reflux secondary to acute
retention rather than compression of both ureters. Clinicians should
therefore be alert to this possibility in future and consider repeat
imaging and renal function tests to assess for resolution of obstructive
uropathy resulting from a herniated bladder.